Accident Details
Probable Cause and Findings
Company maintenance personnel's inappropriate removal without replacement of the safety wires on the collective lever pin screws during a recent maintenance inspection, which resulted in the screws backing out and led to a loss of collective control in flight.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHTOn July 11, 2016, at 1123 central daylight time, a Bell 407, N427TV, collided with terrain during the approach to landing at the Tennessee Valley Authority (TVA) Mayfield Customer Service Center, Hickory, Kentucky. The commercial pilot was fatally injured, and the helicopter was substantially damaged by impact forces. The helicopter was registered to and operated by the TVA under the provisions of 14 Code of Federal Regulations Part 91 as a business flight. Day visual meteorological conditions prevailed, and no flight plan was filed. The flight originated from Outlaw Field Airport (CKV), Clarksville, Tennessee at 1048.
According to TVA personnel, the pilot flew the helicopter from Knoxville, Tennessee, to CKV, refueled, and then flew to the TVA Customer Service Center to pick up a maintenance lineman for the purpose of inspecting power lines and equipment.
According to a TVA lineman who witnessed the accident, there was a light wind from the south/southeast, and the helicopter appeared to be making its final approach from the north. The witness stated that there were no abnormalities in the helicopter's sound or position, until the helicopter was about 75 to 100 ft above the ground. He then observed the main rotor abruptly tilt to the right. Immediately after, the helicopter banked right, fell to the ground, and came to rest on its right side. The witness stated that he never lost sight of the helicopter and described the impact as very hard with no sliding or bouncing. He saw the rotor blades break apart. The witness then ran into the building to get help. The helicopter's engine continued to run after the accident and was subsequently shut down by responding personnel.
Initial examination of the wreckage revealed that the collective lever, which connected the cockpit collective controls to the main rotor, was disconnected from the pivot sleeve. The attaching hardware for the lever was subsequently found loose in the wreckage near the main rotor hub. PERSONNEL INFORMATIONThe pilot, who was seated in the right cockpit seat, held a Federal Aviation Administration (FAA) commercial pilot certificate with airplane single-engine land, rotorcraft-helicopter, instrument airplane, and instrument helicopter ratings. He held an FAA second-class medical certificate with a restriction to wear corrective lenses.
The pilot reported 18,430 total hours of flying experience on his latest medical certificate application, which was dated March 31, 2016. TVA personnel reported that his flight experience in the Bell 407 was about 850 hours. He completed a flight review in a MD Helicopters MD530 helicopter on February 12, 2016, and a flight review in the Bell 407 on January 5, 2016. AIRCRAFT INFORMATIONThe helicopter was a Bell Helicopter model 407, serial number 54106, built in 2012 and purchased new by the TVA. It was a single-engine helicopter of conventional construction and equipped with a four-blade, soft-in-plane design, composite hub, main rotor system, a full monocoque aluminum-skinned tail boom, and a conventional two-blade tail rotor system.
The helicopter was powered by a Rolls-Royce model 250-C47B turboshaft engine, serial number CAE-848434, with maximum takeoff and maximum continuous power ratings of 650 and 600 shaft horsepower, respectively.
The helicopter was issued a normal category standard airworthiness certificate and was maintained under an approved aircraft inspection program. Between May 31, 2016, and June 20, 2016, the helicopter was at the TVA maintenance facility at Muscle Shoals, Alabama, and the following inspections were accomplished: annual/50hr/100 hr, 150hr, 300 hr, 300hr/12 month, 600hr/12 month, 1200 hr/2 year, 12-month and 24-month inspections. From June 20, 2016, until the time of the accident, the helicopter was operated about 38.4 hours.
The collective lever was located at the front and bottom of the swashplate support. The collective lever and collective control link were designed to move the pivot sleeve vertically on the swashplate support to change the pitch on all the main rotor blades simultaneously. The collective lever was attached to the pivot sleeve with screws, washers, and pivot pins (see figure 1). Once attached, the and the specified torque was applied, locking wire would typically be affixed to the screw.
Figure 1 - Swashplate support assembly, with collective pitch lever attaching hardware outlined in red.
The maintenance tasks performed during the inspections between May 31, 2016, and June 20, 2016, did not require the removal of the collective lever or the disconnection or inspection of the collective lever pins or screws. Although an inspection of the condition of the flight control bolts and nuts was one of the maintenance tasks performed, an inspection of the collective lever pins, screws, and corresponding lockwire was not included in that inspection.
The maintenance and inspections of the helicopter's flight controls, including the collective control, were performed by two TVA airframe and powerplant mechanics and one TVA foreman, who assisted in the work and supervised the operation. All three employees were interviewed by FAA inspectors following the accident.
One of the mechanics re-installed an anti-drive lever assembly. He did not recall removing the lockwire on the collective lever pin screws or removing the pins. He stated that the other mechanic performed the 24-month inspection of the flight control bolts and nuts. He further stated that the collective lever pins were not part of that inspection.
The other mechanic performed the 24-month inspection of the flight control bolts and nuts. When asked if he removed the collective lever pins, he responded, "No, I don't remember doing it. If anyone would have done it, it would have been me, but I don't remember doing it."
The foreman inspected the work performed in the area of the flight controls. He reported that the removal of the collective lever pins "…was not part of the required maintenance performed." He was not aware that the pins were removed or that any lockwire was removed. He added further, "I could see why it could have been done. The 24-month flight control bolt inspection was being performed, why not pull them and look at them too. I've done it before."
Both mechanics reported that they would occasionally be "pulled off" an aircraft to perform work on another project. One mechanic stated that there was a lack of documentation of what parts were removed, such as a continuation sheet. METEOROLOGICAL INFORMATIONMayfield - Graves County Airport (M25), Mayfield, Kentucky, was the closest official weather station, which was 8 miles from the accident location. The M25 weather at 1135 included wind from 120° at 5 knots, visibility 10 statute miles, scattered clouds at 1,000 and 2,200 ft, overcast ceiling at 10,000 ft, temperature 26°C, dew point 22°C, and altimeter setting 30.06 inches of Mercury. AIRPORT INFORMATIONThe helicopter was a Bell Helicopter model 407, serial number 54106, built in 2012 and purchased new by the TVA. It was a single-engine helicopter of conventional construction and equipped with a four-blade, soft-in-plane design, composite hub, main rotor system, a full monocoque aluminum-skinned tail boom, and a conventional two-blade tail rotor system.
The helicopter was powered by a Rolls-Royce model 250-C47B turboshaft engine, serial number CAE-848434, with maximum takeoff and maximum continuous power ratings of 650 and 600 shaft horsepower, respectively.
The helicopter was issued a normal category standard airworthiness certificate and was maintained under an approved aircraft inspection program. Between May 31, 2016, and June 20, 2016, the helicopter was at the TVA maintenance facility at Muscle Shoals, Alabama, and the following inspections were accomplished: annual/50hr/100 hr, 150hr, 300 hr, 300hr/12 month, 600hr/12 month, 1200 hr/2 year, 12-month and 24-month inspections. From June 20, 2016, until the time of the accident, the helicopter was operated about 38.4 hours.
The collective lever was located at the front and bottom of the swashplate support. The collective lever and collective control link were designed to move the pivot sleeve vertically on the swashplate support to change the pitch on all the main rotor blades simultaneously. The collective lever was attached to the pivot sleeve with screws, washers, and pivot pins (see figure 1). Once attached, the and the specified torque was applied, locking wire would typically be affixed to the screw.
Figure 1 - Swashplate support assembly, with collective pitch lever attaching hardware outlined in red.
The maintenance tasks performed during the inspections between May 31, 2016, and June 20, 2016, did not require the removal of the collective lever or the disconnection or inspection of the collective lever pins or screws. Although an inspection of the condition of the flight control bolts and nuts was one of the maintenance tasks performed, an inspection of the collective lever pins, screws, and corresponding lockwire was not included in that inspection.
The maintenance and inspections of the helicopter's flight controls, including the collective control, were performed by two TVA airframe and powerplant mechanics and one TVA foreman, who assisted in the work and supervised the operation. All three employees were interviewed by FAA inspectors following the accident.
One of the mechanics re-installed an anti-drive lever assembly. He did not recall removing the lockwire on the collective lever pin screws or removing the pins. He stated that the other mechanic performed the 24-month inspection of the flight control bolts and nuts. He further stated that the collective lever pins were not part of that inspection.
The other mechanic performed the 24-month inspection of the flight control bolts and nuts. When asked if he removed the collective lever pins, he responded, "No, I don't remember doing it....
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# ERA16FA248